Addressing the audience at the Spectrum meeting (18–21 January, Miami, USA), Theresa Caridi (MedStar Georgetown University Hospital, Washington, DC, USA) expands on the pros and cons of uterine artery embolization (UAE), and shares what factors she believes are necessary to discuss with the patient prior to the procedure.
Firstly, Caridi discussed the issue of fertility. In a 2008 study published in the Journal of Cardiovascular and Interventional Radiology (CVIR) by Michal Mara (General Faculty Hospital and First Medical Faculty of Charles University, Prague, Czech Republic) and colleagues, the authors concluded that, while UAE is less invasive and as symptomatically effective and safe as myomectomy, but has inferior reproductive outcomes in the first two years after treatment. One-hundred-and-twenty-one women with reproductive plans who presented with an intramural fibroid(s) larger than 4cm were randomly selected for either UAE or myomectomy; 58 embolizations and 63 myomectomies (42 laparoscopic, 21 open) were performed. Mara et al reported significantly more pregnancies and labours (33 and 19, respectively) and fewer abortions (six) following surgery than after embolization (17 pregnancies, five labours, nine abortions; p<0.05).
Listing her first positive for UAE, Caridi told the Spectrum audience how the procedure is uterine-sparing. Citing a study by Shannon Laughlin-Tommaso (Mayo Clinic, Rochester, USA) published in Menopause in 2018, Caridi demonstrated that ovarian-sparing hysterectomy, which had been touted as a potential way of avoiding some of the detrimental effects of hysterectomy, did not fully eliminate the risks. The Menopause study looked at approximately 2,000 women who had an ovarian-sparing hysterectomy and compared them to age-matched controls. Laughlin-Tommaso and colleagues found that even with ovarian conservation, there is an elevated long-term risk of cardiovascular disease and metabolic conditions, especially in women who undergo hysterectomy when 35 or younger. The authors concluded: “If these associations are causal, alternatives to hysterectomy should be considered to treat benign gynaecologic conditions.”
“Women are talking about this on social media,” Caridi commented. “They are asking ‘What are the risks if I have a hysterectomy, even if I leave the ovaries behind?’ I think it is important to know about this.”
However, while UAE offers a uterine-sparing alternative to hysterectomy, Caridi said that the presence of the uterus “means that we can get fibroid recurrence”. Sharing the five-year results of the prospective, randomised controlled REST trial, which directly compared UAE to surgical treatments—both myomectomy and hysterectomy—in patients with symptomatic uterine fibroids, Caridi reported how the authors, Jon Moss (Gartnavel General Hospital, Glasgow, UK) et al, found that adverse event rates were no different between the UAE and surgical arms, but that the reintervention rate was much higher with UAE. Moss and colleagues’ conclusion in 2011 was that “UAE is a satisfactory alternative to surgery for fibroids”, but that “the less invasive nature of UAE needs to be balanced against the need for re-intervention in almost a third of patients”. They recommended that the choice should lie with the informed patient.
In defence of UAE, Caridi added: “That being said, some of those people who got surgery actually got a hysterectomy, so of course they are not going to need a reintervention more than likely, whereas people who get a myomectomy may, so there is a little bit of bias. But several studies, some out to ten years, do show that the reintervention rate with UAE is about 30%.”
Moving on to her next pro of UAE, Caridi said: “UAE is very efficacious. In fact, it is one of the most efficacious procedures we do in interventional radiology (IR).” The clinical practice guidelines from the Society of Interventional Radiology (SIR) summarise the data in the literature, and show that, on average, “rates of success are really good”: leiomyoma size reduction, 50–60%; uterine size reduction, 40–50%; reduction of bulk symptoms, 88–92%; elimination of abnormal uterine bleeding, >90%; successful elimination of symptoms, 75%; patient satisfaction (would recommend UAE to a friend), 80–90%.
However, another con of UAE is the possibility of fibroid passage. “We treat fibroids really well, but sometimes they detach and pass,” Caridi explained. “We have to worry about that, particularly in submucosal fibroids.”
A meta-analysis from Sundeep Toor (The Ottawa Hospital and University of Ottawa, Ottawa, Canada) et al published in the American Journal of Roentgenology in 2012 reported an incidence of leiomyoma tissue passage of 4.7% (with a range of 3.9–5.7% in 8,159 patients). “That is much higher in a risky site like the submucosal location,” Caridi commented. “It is something we have to worry about. What is the consequence of this [fibroid passage]? Patients can get endometritis and infection and require a secondary intervention. Maybe it is a myomectomy, maybe it is a hysterectomy, if you cannot get the infection under control. Or, they can just get a chronic vaginal discharge that lasts upwards of six months or even a year, and some would like to have a hysterectomy for that reason.”
Returning to her pros of UAE list, Caridi said that “probably one of the key reasons why women seek” UAE is that the recovery time is shorter than for surgical intervention. In the CVIR study by Mara and colleagues that demonstrated the inferior reproductive outcomes of UAE when compared with myomectomy, the authors also reported that the minimally-invasive option fared much better than myomectomy, with significance, for average length of hospital stay, recovery period, and disability greater than two weeks. “It is a quicker recovery, no doubt,” Caridi stated.
She continued, “Though there is a lot of pain associated with UAE”. She elaborated: “Despite our best efforts to look into this in many ways, and all the research that has been done—we have this arsenal of anti-inflammatory and PCA [patient-controlled analgesia] medications, [but] more than 90% of women still report post-procedural pain, and about 35% of women experience pain that is equal to or greater than [that experienced in] labour. So this is a real issue.
“In terms of how to mitigate this, we have some adjunctive techniques, but some of them require a second procedure or have their own risks. We could use superior hypogastric nerve block, intra-arterial lidocaine after embolization—this is pretty widely used as its low-risk profile has been shown in a prospective randomised controlled trial—and then you could go as far as to perform an epidural if you cannot get the pain under control.”
Informed consent is key
Concluding, Caridi commented: “All that being said, I think the summary of this lecture is that there are a lot of pros and a lot of cons to doing a UAE, but the most important factor is to discuss these in a clinic visit.”
Caridi showed the Spectrum audience a consent form that she uses in her own institution, Georgetown University Hospital, that she said she would be happy to share with any interested parties. “We go over all these things with the patient,” she explained. “It helps me stay on track. I sign it, they sign it, I give them a copy.”
The form covers a description of the procedure and the anticipated outcomes: “I tell them [the patient] this is a global treatment, it is uterine-sparing, it is about 90% efficacious, the recovery time is limited. I tell them to take a week off work, although they oftentimes do not need it, but at least they have planned ahead.
“We talk about the alternatives. We talk about the risks, some of which—but this is not an inclusive list—are fibroid recurrence, passage, and pain. Then we talk about future fertility, this actually has its own category. There is no guarantee for future fertility, and if someone desires that, we certainly talk about whether they are a myomectomy candidate.”